RENAL FAILURE: CHRONIC

Chronic renal failure (CRF) is the end result of a gradual, progressive loss of kidney function. Causes include chronic
infections (glomerulonephritis, pyelonephritis), vascular diseases (hypertension, nephrosclerosis), obstructive
processes (renal calculi), collagen diseases (systemic lupus), nephrotoxic agents (drugs, such as aminoglycosides), and
endocrine diseases (diabetes, hyperparathyroidism). This syndrome is generally progressive and produces major
changes in all body systems. The final stage of renal dysfunction, end-stage renal disease (ESRD), is demonstrated by
a glomeruler filtration rate (GFR) of 15%–20% of normal or less.

CARE SETTING
Primary focus is at the community level, although inpatient acute hospitalization may be required for life-threatening
complications.

RELATED CONCERNS
Anemias (iron deficiency, pernicious, aplastic, hemolytic)
Fluid and electrolyte imbalances
Heart failure: chronic
Hypertension: severe
Metabolic acidosis (primary base bicarbonate deficiency)
Psychosocial aspects of care
Upper gastrointestinal/esophageal bleeding
Additional associated nursing diagnoses are found in:
Renal dialysis
Renal failure: acute
Seizure disorders/epilepsy

Patient Assessment Database

ACTIVITY/REST
May report: Extreme fatigue, weakness, malaise
Sleep disturbances (insomnia/restlessness or somnolence)
May exhibit: Muscle weakness, loss of tone, decreased range of motion (ROM)

CIRCULATION
May report: History of prolonged or severe hypertension
Palpitations; chest pain (angina)
May exhibit: Hypertension; JVD, full/bounding pulses; generalized tissue and pitting edema of feet,
legs, hands
Cardiac dysrhythmias, distant heart sounds
Weak thready pulses, orthostatic hypotension reflects hypovolemia (rare in end-stage
disease)
Pericardial friction rub
Pallor; bronze-gray, yellow skin
Bleeding tendencies

EGO INTEGRITY
May report: Stress factors, e.g., financial, relationship, and so on
Feelings of helplessness, hopelessness, powerlessness
May exhibit: Denial, anxiety, fear, anger, irritability, personality changes

ELIMINATION
May report: Decreased urinary frequency; oliguria, anuria (advanced failure)
Abdominal bloating, diarrhea, or constipation
May exhibit: Change in urine color, e.g., deep yellow, red, brown, cloudy
 Oliguria, may become anuric

FOOD/FLUID
May report: Rapid weight gain (edema), weight loss (malnutrition)
Anorexia, heartburn, nausea/vomiting; unpleasant metallic taste in the mouth (ammonia
breath)
Use of diuretics
May exhibit: Abdominal distension/ascites, liver enlargement (end-stage)
Changes in skin turgor/moisture
Edema (generalized, dependent)
Gum ulcerations, bleeding of gums/tongue
Muscle wasting, decreased subcutaneous fat, debilitated appearance

HYGIENE
May report: Difficulty performing activities of daily living (ADLs)

NEUROSENSORY
May report: Headache, blurred vision
Muscle cramps/twitching, “restless leg” syndrome; burning numbness of soles of feet
Numbness/tingling and weakness, especially of lower extremities (peripheral neuropathy)
May exhibit: Altered mental state, e.g., decreased attention span, inability to concentrate, loss of
memory, confusion, decreasing level of consciousness, stupor, coma
Gait abnormalities
Twitching, muscle fasciculations, seizure activity
Thin, dry, brittle nails and hair

PAIN/DISCOMFORT
May report: Flank pain; headache; muscle cramps/leg pain (worse at night)
May exhibit: Guarding/distraction behaviors, restlessness

RESPIRATION
May report: Shortness of breath; paroxysmal nocturnal dyspnea; cough with/without thick, tenacious
sputum
May exhibit: Tachypnea, dyspnea, increased rate/depth (Kussmaul’s respiration)
Cough productive of pink-tinged sputum (pulmonary edema)

SAFETY
May report: Itching skin, frequent scratching
Recent/recurrent infections
May exhibit: Scratch marks, petechiae, ecchymotic areas on skin
Fever (sepsis, dehydration); normothermia may actually represent an elevation in patient
who has developed a lower-than-normal body temperature (effect of CRF/
depressed immune response)
Bone fractures; calcium phosphate deposits (metastatic calcifications) in skin, soft tissues,
joints; limited joint movement

SEXUALITY
May report: Decreased libido; amenorrhea; infertility

SOCIAL INTERACTION
May report: Difficulties imposed by condition, e.g., unable to work, maintain social contacts or usual
role function in family

TEACHING/LEARNING
May report: Family history of polycystic disease, hereditary nephritis, urinary calculus, malignancy
History of DM (high risk for renal failure); exposure to toxins, e.g., nephrotoxic drugs,
drug overdose, environmental poisons
 Current/recent use of nephrotoxic antibiotics, angiotensin-converting enzyme (ACE)
inhibitors, chemotherapy agents, heavy metals, nonsteroidal anti-inflammatory
drugs (NSAIDs), radiocontrast agents
Discharge plan DRG projected mean length of inpatient stay: 5.9 days
considerations: May require alteration/assistance with medications, treatments, supplies; transportation,
homemaker/maintenance tasks
Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES
Urine:
Volume: Usually less than 400 mL/24 hr (oliguria) or urine is absent (anuria).
Color: Abnormally cloudy urine may be caused by pus, bacteria, fat, colloidal particles, phosphates, or urates.
Dirty, brown sediment indicates presence of RBCs, hemoglobin, myoglobin, porphyrins.
Specific gravity: Less than 1.015 (fixed at 1.010 reflects severe renal damage).
Osmolality: Less than 350 mOsm/kg is indicative of tubular damage, and urine/serum ratio is often 1:1.
Creatinine clearance: May be significantly decreased (less than 80 mL/min in early failure; less than 10 mL/min
in ESRD).
Sodium: More than 40 mEq/L because kidney is not able to reabsorb sodium.
Protein: High-grade proteinuria (3–4+) strongly indicates glomerular damage when RBCs and casts are also
present.
Blood:
BUN/Cr: Elevated, usually in proportion. Creatinine level of 12 mg/dL suggests ESRD. A BUN of >25 mg/dL is
indicative of renal damage.
CBC: Hb decreased because of anemia, usually less than 7–8 g/dL.
RBCs: Life span decreased because of erythropoietin deficiency, and azotemia.
ABGs: pH decreased. Metabolic acidosis (less than 7.2) occurs because of loss of renal ability to excrete hydrogen
and ammonia or end products of protein catabolism. Bicarbonate and PCO2 decreased.
Serum sodium: May be low (if kidney “wastes sodium”) or normal (reflecting dilutional state of hypernatremia).
Potassium: Elevated related to retention and cellular shifts (acidosis) or tissue release (RBC hemolysis). In ESRD,
ECG changes may not occur until potassium is 6.5 mEq or higher. Potassium may also be decreased if
patient is on potassium-wasting diuretics or when patient is receiving dialysis treatment.
Magnesium, phosphorus: Elevated.
Calcium/phosphorus: Decreased.
Proteins (especially albumin): Decreased serum level may reflect protein loss via urine, fluid shifts, decreased
intake, or decreased synthesis because of lack of essential amino acids.
Serum osmolality: Higher than 285 mOsm/kg; often equal to urine.
KUB x-rays: Demonstrates size of kidneys/ureters/bladder and presence of obstruction (stones).
Retrograde pyelogram: Outlines abnormalities of renal pelvis and ureters.
Renal arteriogram: Assesses renal circulation and identifies extravascularities, masses.
Voiding cystourethrogram: Shows bladder size, reflux into ureters, retention.
Renal ultrasound: Determines kidney size and presence of masses, cysts, obstruction in upper urinary tract.
Renal biopsy: May be done endoscopically to examine tissue cells for histological diagnosis.
Renal endoscopy, nephroscopy: Done to examine renal pelvis; flush out calculi, hematuria; and remove selected
tumors.
ECG: May be abnormal, reflecting electrolyte and acid-base imbalances.
X-ray of feet, skull, spinal column, and hands: May reveal demineralization/calcifications resulting from electrolyte
shifts associated with CRF.

NURSING PRIORITIES
1. Maintain homeostasis.
2. Prevent complications.
3. Provide information about disease process/prognosis and treatment needs.
4. Support adjustment to lifestyle changes.

DISCHARGE GOALS
1. Fluid/electrolyte balance stabilized.
2. Complications prevented/minimized.
3. Disease process/prognosis and therapeutic regimen understood.
4. Dealing realistically with situation; initiating necessary lifestyle changes.
5. Plan in place to meet needs after discharge.

NURSING DIAGNOSIS: Cardiac Output, risk for decreased

Risk factors may include
Fluid imbalances affecting circulating volume, myocardial workload, and systemic vascular resistance (SVR)
Alterations in rate, rhythm, cardiac conduction (electrolyte imbalances, hypoxia)
Accumulation of toxins (urea), soft-tissue calcification (deposition of calcium phosphate)
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Circulation Status (NOC)
Maintain cardiac output as evidenced by BP and heart rate within patient’s normal range; peripheral pulses
strong and equal with prompt capillary refill time.

ACTIONS/INTERVENTIONS RATIONALE
(In addition to those in CP: Renal Failure: Acute; ND: Cardiac Output, risk for decreased.)

ACTIONS/INTERVENTIONS RATIONALE
Hemodynamic Regulation (NIC)

Independent
Auscultate heart and lung sounds. Evaluate presence of S3/S4 heart sounds with muffled tones, tachycardia,
peripheral edema/vascular congestion and reports of irregular heart rate, tachypnea, dyspnea, crackles,
dyspnea. wheezes, and edema/jugular distension suggest HF.

Assess presence/degree of hypertension: monitor BP; note
postural changes, e.g., sitting, lying, standing.
Significant hypertension can occur because of
disturbances in the renin-angiotensin-aldosterone system
(caused by renal dysfunction). Although hypertension is
common, orthostatic hypotension may occur because of
intravascular fluid deficit, response to effects of
antihypertensive medications, or uremic pericardial
tamponade.

Investigate reports of chest pain, noting location, Although hypertension and chronic HF may cause MI,
radiation, severity (0–10 scale), and whether or not it is approximately half of CRF patients on dialysis develop
intensified by deep inspiration and supine position. pericarditis, potentiating risk of pericardial
effusion/tamponade.

Evaluate heart sounds (note friction rub), BP, peripheral
pulses, capillary refill, vascular congestion, temperature,
and sensorium/mentation.
Presence of sudden hypotension, paradoxic pulse, narrow
pulse pressure, diminished/absent peripheral pulses,
marked jugular distension, pallor, and a rapid mental
deterioration indicate tamponade, which is a medical
emergency.

ACTIONS/INTERVENTIONS RATIONALE
Hemodynamic Regulation (NIC)

Independent
Assess activity level, response to activity. Weakness can be attributed to HF and anemia.

Collaborative

Monitor laboratory/diagnostic studies, e.g.:

Electrolytes (potassium, sodium, calcium, Imbalances can alter electrical conduction and cardiac
magnesium), BUN/Cr; function.

Chest x-rays. Useful in identifying developing cardiac failure or soft-

tissue calcification.

Administer antihypertensive drugs, e.g., prazosin Reduces systemic vascular resistance and/or renin release
(Minipress), captopril (Capoten), clonidine (Catapres), to decrease myocardial workload and aid in prevention of
hydralazine (Apresoline). HF and/or MI.

Prepare for dialysis. Reduction of uremic toxins and correction of electrolyte

imbalances and fluid overload may limit/prevent cardiac
manifestations, including hypertension and pericardial
effusion.

Assist with pericardiocentesis as indicated. Accumulation of fluid within pericardial sac can
compromise cardiac filling and myocardial contractility,
impairing cardiac output and potentiating risk of cardiac
arrest.

NURSING DIAGNOSIS: Protection, risk for ineffective

Risk factors may include
Abnormal blood profile (suppressed erythropoietin production/secretion; decreased RBC production and
survival; altered clotting factors; increased capillary fragility)
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Coagulation Status (NOC)
Experience no signs/symptoms of bleeding/hemorrhage.
Maintain/demonstrate improvement in laboratory values.
ACTIONS/INTERVENTIONS
Energy Management (NIC)
Independent
Note reports of increasing fatigue, weakness. Observe for
tachycardia, pallor of skin/mucous membranes, dyspnea,
and chest pain. Plan patient activities to avoid fatigue.
Monitor level of consciousness and behavior.
Evaluate response to activity, ability to perform tasks.
Assist as needed and develop schedule for rest.
Limit vascular sampling, combine laboratory tests when
possible.
Bleeding Precautions (NIC)
Observe for oozing from venipuncture sites,
bleeding/ecchymotic areas following slight trauma,
petechiae; joint swelling or mucous membrane
involvement, e.g., bleeding gums, recurrent epistaxis,
hematemesis, melena, and hazy/red urine.
Hematest GI secretions/stool for blood.
Provide soft toothbrush, electric razor; use smallest
needle possible and apply prolonged pressure following
injections/vascular punctures.
Collaborative
Monitor laboratory studies, e.g.:
RBCs, Hb/Hct;
Platelet count, clotting factors;
Prothrombin time (PT) level.
RATIONALE
May reflect effects of anemia and cardiac response
necessary to keep cells oxygenated.
Anemia may cause cerebral hypoxia manifested by
changes in mentation, orientation, and behavioral
responses.
Anemia decreases tissue oxygenation and increases
fatigue, which may require intervention, changes in
activity, and rest.
Recurrent/excessive blood sampling can worsen anemia.
Bleeding can occur easily because of capillary
fragility/altered clotting functions and may worsen
anemia.
Mucosal changes and altered platelet function due to
uremia may result in gastric mucosal erosion/GI
hemorrhage.
Reduces risk of bleeding/hematoma formation.
Uremia (e.g., elevated ammonia, urea, other toxins)
decreases production of erythropoietin and depresses
RBC production and survival time. In CRF, Hb and Hct
are usually low but tolerated; e.g., patient may not be
symptomatic until Hb is below 7.
Suppression of platelet formation and inadequate levels of
factors III and VIII impair clotting and potentiate risk of
bleeding. Note: Bleeding may become intractable in
ESRD.
Abnormal prothrombin consumption lowers serum levels
and impairs clotting.
ACTIONS/INTERVENTIONS RATIONALE
Bleeding Precautions (NIC)

Collaborative
Administer fresh blood, packed RBCs (PRCs) as May be necessary when patient is symptomatic with
indicated. anemia. PRCs are usually given when patient is
experiencing fluid overload or receiving dialysis
treatment. Washed RBCs are used to prevent
hyperkalemia associated with stored blood.

Administer medications, as indicated, e.g.:

Erythropoietin preparations (Epogen, EPO, Procrit); Corrects many of the symptoms of CRF resulting from
anemia by stimulating the production and maintenance of
RBCs, thus decreasing the need for transfusion.

Iron preparations: folic acid (Folvite), Useful in managing symptomatic anemia related to
cyanocobalamin (Rubesol-1000); nutritional/dialysis-induced deficits. Note: Iron should not
be given with phosphate binders because they may
decrease iron absorption.

Cimetidine (Tagamet), ranitidine (Zantac); antacids; May be given prophylactically to reduce/neutralize

Hemostatics/fibrinolysis inhibitors, e.g.,
aminocaproic acid (Amicar);
Stool softeners (e.g., Colace); bulk laxative (e.g.,
Metamucil).
gastric acid and thereby reduce the risk of GI
hemorrhage.
Inhibits bleeding that does not subside spontaneously/
respond to usual treatment.
Straining to pass hard-formed stool increases likelihood
of mucosal/rectal bleeding.

NURSING DIAGNOSIS: Thought Processes, disturbed

May be related to
Physiological changes: accumulation of toxins (e.g., urea, ammonia), metabolic acidosis, hypoxia; electrolyte
imbalances, calcifications in the brain
Possibly evidenced by
Disorientation to person, place, time
Memory deficit; altered attention span, decreased ability to grasp ideas
Impaired ability to make decisions, problem-solve
Changes in sensorium: somnolence, stupor, coma
Changes in behavior: irritability, withdrawal, depression, psychosis
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Cognitive Ability (NOC)
Regain/maintain optimal level of mentation.
Identify ways to compensate for cognitive impairment/memory deficits.
ACTIONS/INTERVENTIONS
Reality Orientation (NIC)
Independent
Assess extent of impairment in thinking ability, memory,
and orientation. Note attention span.
Ascertain from SO patient’s usual level of mentation.
Provide SO with information about patient’s status.
Provide quiet/calm environment and judicious use of
television, radio, and visitation.
Reorient to surroundings, person, and so forth. Provide
calendars, clocks, outside window.
Present reality concisely, briefly, and do not challenge
illogical thinking.
Communicate information/instructions in simple, short
sentences. Ask direct, yes/no questions. Repeat
explanations as necessary.
Establish a regular schedule for expected activities.
Promote adequate rest and undisturbed periods for sleep.
Collaborative
Monitor laboratory studies, e.g., BUN/Cr, serum
electrolytes, glucose level, and ABGs (Po2, pH).
Provide supplemental O2 as indicated.
Avoid use of barbiturates and opiates.
Prepare for dialysis.
RATIONALE
Uremic syndrome’s effect can begin with minor
confusion/irritability and progress to altered personality
or inability to assimilate information and participate in
care. Awareness of changes provides opportunity for
evaluation and intervention.
Provides comparison to evaluate progression/resolution of
impairment.
Some improvement in mentation may be expected with
restoration of more normal levels of BUN, electrolytes,
and serum pH.
Minimizes environmental stimuli to reduce sensory
overload/confusion while preventing sensory deprivation.
Provides clues to aid in recognition of reality.
Confrontation potentiates defensive reactions and may
lead to patient mistrust and heightened denial of reality.
May aid in reducing confusion, and increases possibility
that communications will be understood/remembered.
Aids in maintaining reality orientation and may reduce
fear/confusion.
Sleep deprivation may further impair cognitive abilities.
Correction of elevations/imbalances can have profound
effects on cognition/mentation.
Correction of hypoxia alone can improve cognition.
Drugs normally detoxified in the kidneys will have
increased half-life/cumulative effects, worsening
confusion.
Marked deterioration of thought processes may indicate
worsening of azotemia and general condition, requiring
prompt intervention to regain homeostasis.
 NURSING DIAGNOSIS: Skin Integrity, risk for impaired
Risk factors may include
Altered metabolic state, circulation (anemia with tissue ischemia), and sensation (peripheral neuropathy)
Alterations in skin turgor (edema/dehydration)
Reduced activity/immobility
Accumulation of toxins in the skin
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Tissue Integrity: Skin and Mucous Membranes (NOC)
Maintain intact skin.
Risk Management (NOC)
Demonstrate behaviors/techniques to prevent skin breakdown/injury.

ACTIONS/INTERVENTIONS RATIONALE
Skin Surveillance (NIC)

Independent
Inspect skin for changes in color, turgor, vascularity. Note Indicates areas of poor circulation/breakdown that may
redness, excoriation. Observe for ecchymosis, purpura. lead to decubitus formation/infection.

Monitor fluid intake and hydration of skin and mucous Detects presence of dehydration or overhydration that
membranes. affect circulation and tissue integrity at the cellular level.

Inspect dependent areas for edema. Elevate legs as Edematous tissues are more prone to breakdown.
indicated. Elevation promotes venous return, limiting venous
stasis/edema formation.

Change position frequently; move patient carefully; pad Decreases pressure on edematous, poorly perfused tissues
bony prominences with sheepskin, elbow/heel protectors. to reduce ischemia.

Provide soothing skin care. Restrict use of soaps. Apply Baking soda, cornstarch baths decrease itching and are
ointments or creams (e.g., lanolin, Aquaphor). less drying than soaps. Lotions and ointments may be
desired to relieve dry, cracked skin.

Keep linens dry, wrinkle-free. Reduces dermal irritation and risk of skin breakdown.

Investigate reports of itching. Although dialysis has largely eliminated skin problems
associated with uremic frost, itching can occur because
the skin is an excretory route for waste products, e.g.,
phosphate crystals (associated with hyperparathyroidism
in ESRD).

Recommend patient use cool, moist compresses to apply Alleviates discomfort and reduces risk of dermal injury.
pressure (rather than scratch) pruritic areas. Keep
fingernails short; encourage use of gloves during sleep if
needed.
ACTIONS/INTERVENTIONS RATIONALE
Skin Surveillance (NIC)

Independent
Suggest wearing loose-fitting cotton garments. Prevents direct dermal irritation and promotes
evaporation of moisture on the skin.

Collaborative

Provide foam/flotation mattress. Reduces prolonged pressure on tissues, which can limit
cellular perfusion, potentiating ischemia/necrosis.

NURSING DIAGNOSIS: Oral Mucous Membrane, risk for impaired

Risk factors may include
Lack of/or decreased salivation, fluid restrictions
Chemical irritation, conversion of urea in saliva to ammonia
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Oral Health (NOC)
Maintain integrity of mucous membranes.
Identify/initiate specific interventions to promote healthy oral mucosa.

ACTIONS/INTERVENTIONS RATIONALE
Oral Health Maintenance (NIC)

Independent
Inspect oral cavity; note moistness, character of saliva, Provides opportunity for prompt intervention and
presence of inflammation, ulcerations, leukoplakia. prevention of infection.

Provide fluids throughout 24-hr period within prescribed Prevents excessive oral dryness from prolonged period
limit. without oral intake.

Offer frequent mouth care/rinse with 0.25% acetic acid
solution; provide gum, hard candy, breath mints between
meals.
Mucous membranes may become dry and cracked. Mouth
care soothes, lubricates, and helps freshen mouth taste,
which is often unpleasant because of uremia and
restricted oral intake. Rinsing with acetic acid helps
neutralize ammonia formed by conversion of urea.

Encourage good dental hygiene after meals and at Reduces bacterial growth and potential for infection.
bedtime. Recommend avoidance of dental floss. Dental floss may cut gums, potentiating bleeding.
ACTIONS/INTERVENTIONS RATIONALE
Oral Health Maintenance (NIC)

Independent
Recommend patient stop smoking and avoid lemon/ These substances are irritating to the mucosa and have a
glycerine products or mouthwash containing alcohol. drying effect, potentiating discomfort.

Provide artificial saliva as needed, e.g., Ora-Lube. Prevents dryness, buffers acids, and promotes comfort.

Collaborative

Administer medications as indicated, e.g., antihistamines: May be given for relief of itching.
cyproheptadine (Periactin).

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, prognosis,

treatment, self-care, and discharge needs
May be related to
Lack of exposure/recall, information misinterpretation
Cognitive limitation
Possibly evidenced by
Questions/request for information, statement of misconception
Inaccurate follow-through of instructions, development of preventable complications
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Knowledge: Disease Process (NOC)
Verbalize understanding of condition/disease process and potential complications.
Knowledge: Treatment Regimen (NOC)
Verbalize understanding of therapeutic needs.
Correctly perform necessary procedures and explain reasons for the actions.
Demonstrate/initiate necessary lifestyle changes.
Participate in treatment regimen.

ACTIONS/INTERVENTIONS RATIONALE
(In addition to interventions outlined in CP: Renal Failure: Acute; Knowledge, deficient.)
ACTIONS/INTERVENTIONS
Teaching: Disease Process (NIC)
Independent
Review disease process/prognosis and future
expectations.
Review dietary restrictions, including:
Phosphorus (e.g., carbonated drinks, processed
foods, poultry, corn, peanuts) and magnesium (e.g.,
whole grain products, legumes);
Fluid and sodium restrictions when indicated.
Discuss other nutritional concerns, e.g., regulating protein
intake according to level of renal function (generally 0.6–
0.7g/k of body weight per day of good quality protein,
such as meat, eggs).
Encourage adequate calorie intake, especially from
carbohydrates in the nondiabetic patient.
Discuss drug therapy, including use of calcium
supplements and phosphate binders, e.g., aluminum
hydroxide antacids (Amphojel, Basalgel) and avoidance
of magnesium antacids (Mylanta, Maalox, Gelusil);
vitamin D.
Stress importance of reading all product labels (drugs and
food) and not taking medications without prior approval
of healthcare provider.
RATIONALE
Provides knowledge base from which patient can make
informed choices.
Retention of phosphorus stimulates the parathyroid glands
to shift calcium from bones (renal osteodystrophy), and
accumulation of magnesium can impair neuromuscular
function and mentation.
If fluid retention is a problem, patient may need to restrict
intake of fluid to 1100 cc (or less) and restrict dietary
sodium. If fluid overload is present, diuretic therapy or
dialysis will be part of the regimen. (Refer to CP: Renal
Failure, Acute, ND: Fluid Volume excess.)
Metabolites that accumulate in blood derive almost
entirely from protein catabolism; as renal function
declines, proteins may be restricted proportionately. Too
little protein can result in malnutrition. Note: Patient on
dialysis may not need to be as vigilant with protein
intake.
Spares protein, prevents wasting, and provides energy.
Note: Use of special glucose polymer powders can add
calories to enhance energy level without extra food or
fluid intake.
Prevents serious complications, e.g., reducing phosphate
absorption from the GI tract and supplying calcium to
maintain normal serum levels, reducing risk of bone
demineralization/fractures, tetany; however, use of
aluminum-containing products should be monitored
because accumulation in the bones potentiates
osteodystrophy. Magnesium products potentiate risk of
hypermagnesemia. Note: Supplemental vitamin D may be
required to facilitate calcium absorption.
It is difficult to maintain electrolyte balance when
exogenous intake is not factored into dietary restrictions,
e.g., hypercalcemia can result from routine supplement
use in combination with increased dietary intake of
calcium-fortified foods and medications containing
calcium.
ACTIONS/INTERVENTIONS
Teaching: Disease Process (NIC)
Independent
Review measures to prevent bleeding/hemorrhage, e.g.,
use of soft toothbrush, electric razor; avoidance of
constipation, forceful blowing of nose, strenuous
exercise/contact sports.
Instruct in self-observation and self-monitoring of BP,
including scheduling rest period before taking BP, using
same arm/position.
Caution against exposure to external temperature
extremes, e.g., heating pad/snow.
Establish routine exercise program within limits of
individual ability; intersperse adequate rest periods with
activities.
Address sexual concerns.
Identify available resources as indicated. Stress necessity
of medical and laboratory follow-up.
Identify signs/symptoms requiring immediate medical
evaluation, e.g.:
Low-grade fever, chills, changes in characteristics of
urine/sputum, tissue swelling/drainage, oral
ulcerations;
Numbness/tingling of digits, abdominal/muscle
cramps, carpopedal spasms;
Joint swelling/tenderness, decreased ROM, reduced
muscle strength;
Headaches, blurred vision, periorbital/sacral edema,
“red eyes”;
Review strategies to prevent constipation, including
stool softeners (Colace) and bulk laxatives
(Metamucil) but avoiding magnesium products (milk
of magnesia).
RATIONALE
Reduces risks related to alteration of clotting
factors/decreased platelet count.
Incidence of hypertension is increased in CRF, often
requiring management with antihypertensive drugs,
necessitating close observation of treatment effects, e.g.,
vascular response to medication.
Peripheral neuropathy may develop, especially in lower
extremities (effects of uremia, electrolyte/acid-base
imbalances), impairing peripheral sensation and
potentiating risk of tissue injury.
Aids in maintaining muscle tone and joint flexibility.
Reduces risks associated with immobility (including bone
demineralization), while preventing fatigue.
Physiological effects of uremia/antihypertensive therapy
may impair sexual desire/performance.
Close monitoring of renal function and electrolyte
balance is necessary to adjust dietary prescription,
treatment and/or make decisions about possible options
such as dialysis/transplantation.
Depressed immune system, anemia, malnutrition all
contribute to increased risk of infection.
Uremia and decreased absorption of calcium may lead to
peripheral neuropathies.
Hyperphosphatemia with corresponding calcium shifts
from the bone may result in deposition of the excess
calcium phosphate as calcifications in joints and soft
tissues. Symptoms of skeletal involvement are often noted
before impairment in organ function is evident.
Suggestive of development/poor control of hypertension,
and/or changes in eyes caused by calcium.
Reduced fluid intake, changes in dietary pattern, and use
of phosphate-binding products often result in constipation
that is not responsive to nonmedical interventions. Use of
products containing magnesium increases risk of
hypermagnesemia.
POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on patient’s age, physical
condition/presence of complications, personal resources, and life responsibilities)
Fluid Volume excess—compromised regulatory mechanism.
Fatigue—decreased metabolic energy production/dietary restriction, anemia, increased energy requirements, e.g.,
fever/
inflammation, tissue regeneration.
Therapeutic Regimen: ineffective management—complexity of therapeutic regimen, decisional conflicts: patient value
system; health beliefs, cultural influences; powerlessness; economic difficulties; family conflict; lack of/refusal of
support systems.
Hopelessness—deteriorating physiological condition, long-term stress, prolonged activity limitations.